Healthcare Provider Details

I. General information

NPI: 1578040135
Provider Name (Legal Business Name): TRACY MY NGO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2018
Last Update Date: 10/11/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1113 HIGHWAY 49
SAN ANDREAS CA
95249
US

IV. Provider business mailing address

PO BOX 939
ANGELS CAMP CA
95222-0939
US

V. Phone/Fax

Practice location:
  • Phone: 209-755-1460
  • Fax: 209-754-6278
Mailing address:
  • Phone: 209-754-6262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS102710
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: